Case Reports of Toxicity Due to Commercially Available Products

Spontaneous intracerebral hemorrhage occurred in a 72-yr-old woman who had been taking
ginkgo 50 mg three times daily for 6 mo (Gilbert, 1997).
Bilateral subdural hematomas were discovered in a 33-yr-old woman who had been taking 60
mg of GB twice daily for 2 yr, acetaminophen, and occasionally an ergotamine/caffeine
preparation (Rowin and Lewis, 1996). Bleeding time was elevated, but had normalized when
checked approx 1 mo after discontinuation of the product.
In a similar case, a 61-yr-old man presented with a subarachnoid hemorrhage after taking 40
mg GB tablets three or four times daily for >6 mo (Vale, 1998). Bleeding time was elevated
(6 min, normal 1 3), but normalized with discontinuation of the product.
A 78-yr-old woman suffered a left parietal hemorrhage after taking a ginkgo preparation for 2
mo (Matthews, 1998). Other medications included warfarin, which she had been taking for 5
yr after undergoing coronary bypass. Prothrombin time was unchanged.
A 70-yr-old man experienced bleeding from the iris into the anterior chamber after selfmedicating with 40 mg of Ginkobatwice daily for 1 wk (Rosenblatt and Mindel, 1997).
Other medications included 325 mg of aspirin daily for 3 yr post-coronary bypass. Ginkgo,
but not aspirin, was discontinued, and no further bleeding problems occurred.
''Gin-nan" food poisoning, a toxic syndrome associated with ingestion of 50 or more ginkgo
seeds, can result in loss of consciousness, tonic/clonic seizures, and/or death (Anonymous,
1998). Seventy cases were reported between 1930 and 1960, with a 27% mortality rate.
Infants were at greatest risk.
Although ginkgotoxin (4-O-methylpyridoxine), which is found mostly in the seeds, has been
implicated as the responsible neurotoxin, its concentrations in several commercially available
ginkgo products tested were deemed too low to have a toxic effect (Arenz et al., 1996). If used
as directed, the maximum daily intake of4-O-methylpyridoxine would be approx 60 g;
however, the presence of this neurotoxin raises questions about the herb's ability to lower the
seizure threshold in patients with seizure disorders (Arenz et al., 1996). The authors of this
study cite evidence that bilobalide present in the formulations may decrease the severity of
convulsions, thus counteracting any neurotoxic effects of 4-O-methylpyridoxine.
Adverse effects listed in the German Commission E Ginkgo biloba leaf extract monograph
include gastrointestinal upset, headache, and rash (Blumenthal, 1998).